Team Lead, Care Specialist UM - REMOTE

Summary of Position

Support the non-clinical functions required for successful Utilization Management. Ensure all work assigned to or by this position is completed in appropriate timeframes and in keeping with all organizational, regulatory and legal requirement. Responsible for direct supervision for 5 - 8+ non-clinical staff. Responsible for day-to-day oversight of workload balance among team members, staff assignment planning, and reporting oversight. Represent the team and/or Supervisor in projects/initiatives by participating in requirements, design and development and testing sessions or other meetings as appropriate. Responsible for a caseload 50% of the time. Povide services per the NYCE contract.

Principal Accountabilities

• Direct oversight of Care Specialists and Sr. Care Specialists, including 1:1 meetings and yearly performance evaluations.
• Provide oversight/mentoring of new employees with ongoing performance coaching.
• In conjunction with the Supervisor, participate in the PIP process for assigned staff. Also participate in the hiring process with the Supervisor.
• Provide direction to the team on daily work, schedules, issues, questions, etc.
• Resolve escalated or executive issues.
• Serve as subject matter expert in processes and procedures, use of system, delegated relationships that demonstrate a higher level of clinical functioning in role.
• Identify issues, escalate, and communicate with leadership to initiate problem solving.
• Ensure organizational, legal and regulatory requirements are met for work assigned to or by this position.
• Provide case review (when necessary) and assure timely notification and correspondence to facilities, members, and providers.
• Maintain a daily caseload in accordance to the productivity needs of the Total Population Health team.
• Conduct preauthorization review activities in support of clinical staff responsible for determinations, including management of benefit exclusion determinations, in accordance with departmental policies.
• Communicate authorization decisions and important benefit information to providers and members in accordance with applicable standards.
• Interact with various departments throughout the Enterprise and contribute to the resolution of interdepartmental issues.
• Lead and develop team to quickly assess and diagnose root causes.
• Research and resolve claim/referral and authorization discrepancies/issues to facilitate timely and accurate claims adjudication in compliance with company policy and regulatory requirements.
• Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
• Work collaboratively with delegates to promote and maintain all established processes, policies and relationships.
• Work collaboratively with senior leadership as a critical component of the multi-disciplinary team to facilitate all nonclinical processes and activities.
• Train and develop assigned staff under the direction of the Manager/Lead.
• Perform other related projects and duties as assigned or required.